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First drug for spinal muscular atrophy approved
The antisense oligonucleotide drug nusinersen is the first therapy approved by the U.S. Food and Drug Administration to treat children and adults with spinal muscular atrophy.
The drug was developed by Ionis Pharmaceuticals and will be marketed by Biogen under the brand name Spinraza. The antisense oligonucleotide drug is administered via an intrathecal injection and promotes transcription of the full-length survival motor neuron (SMN) protein from the SMN2 gene.
The efficacy of nusinersen was tested during a randomized clinical trial in 121 patients with infantile-onset spinal muscular atrophy who were diagnosed before the age of 6 months or were younger than 7 months at the time of their first dose. Patients were randomized 2:1 to receive an injection of nusinersen into the fluid surrounding the spinal cord or undergo a mock procedure without drug injection (a skin prick).
A total of 82 of 121 patients who were randomized were eligible for an interim analysis of the results that was requested by the FDA. The results showed 40% of patients treated with nusinersen achieved improvement in motor milestones as defined in the study, whereas none of the control patients did. The side effects during the clinical trials among patients on nusinersen included upper respiratory infection, lower respiratory infection, and constipation. Warnings and precautions include low blood platelet count and renal toxicity. Neurotoxicity was observed in animal studies.
Read the full announcement from the agency here.
The antisense oligonucleotide drug nusinersen is the first therapy approved by the U.S. Food and Drug Administration to treat children and adults with spinal muscular atrophy.
The drug was developed by Ionis Pharmaceuticals and will be marketed by Biogen under the brand name Spinraza. The antisense oligonucleotide drug is administered via an intrathecal injection and promotes transcription of the full-length survival motor neuron (SMN) protein from the SMN2 gene.
The efficacy of nusinersen was tested during a randomized clinical trial in 121 patients with infantile-onset spinal muscular atrophy who were diagnosed before the age of 6 months or were younger than 7 months at the time of their first dose. Patients were randomized 2:1 to receive an injection of nusinersen into the fluid surrounding the spinal cord or undergo a mock procedure without drug injection (a skin prick).
A total of 82 of 121 patients who were randomized were eligible for an interim analysis of the results that was requested by the FDA. The results showed 40% of patients treated with nusinersen achieved improvement in motor milestones as defined in the study, whereas none of the control patients did. The side effects during the clinical trials among patients on nusinersen included upper respiratory infection, lower respiratory infection, and constipation. Warnings and precautions include low blood platelet count and renal toxicity. Neurotoxicity was observed in animal studies.
Read the full announcement from the agency here.
The antisense oligonucleotide drug nusinersen is the first therapy approved by the U.S. Food and Drug Administration to treat children and adults with spinal muscular atrophy.
The drug was developed by Ionis Pharmaceuticals and will be marketed by Biogen under the brand name Spinraza. The antisense oligonucleotide drug is administered via an intrathecal injection and promotes transcription of the full-length survival motor neuron (SMN) protein from the SMN2 gene.
The efficacy of nusinersen was tested during a randomized clinical trial in 121 patients with infantile-onset spinal muscular atrophy who were diagnosed before the age of 6 months or were younger than 7 months at the time of their first dose. Patients were randomized 2:1 to receive an injection of nusinersen into the fluid surrounding the spinal cord or undergo a mock procedure without drug injection (a skin prick).
A total of 82 of 121 patients who were randomized were eligible for an interim analysis of the results that was requested by the FDA. The results showed 40% of patients treated with nusinersen achieved improvement in motor milestones as defined in the study, whereas none of the control patients did. The side effects during the clinical trials among patients on nusinersen included upper respiratory infection, lower respiratory infection, and constipation. Warnings and precautions include low blood platelet count and renal toxicity. Neurotoxicity was observed in animal studies.
Read the full announcement from the agency here.
A Rare Association in Down Syndrome: Milialike Idiopathic Calcinosis Cutis and Palpebral Syringoma
To the Editor:
Down syndrome (DS) is associated with rare dermatological disorders, and the prevalence of some common dermatoses is greater in patients with DS. We report a case of milialike idiopathic calcinosis cutis (MICC) associated with syringomas in a patient with DS. We emphasize that MICC is one of the rare dermatoses associated with DS.
A 4-year-old girl with DS presented with a 4-mm, flesh-colored, regular-bordered, exophytic papular lesion on the left upper eyelid of 8 months' duration (Figure 1). It was clinically recognized as syringoma. On dermatologic examination of the patient, there also were 1- to 3-mm, round, whitish, painless, milialike papules on the dorsal surface of the hands and wrists (Figure 2). Some of these papules were surrounded by erythema. There was no sign of perforation. Her personal and family history were unremarkable.
Histopathologic examination of a biopsy from a milialike lesion on the hand showed a hyperkeratotic epidermis. In the dermis there was a roundish calcific nodule surrounded by a fibrovascular rim. The patient's guardians refused a biopsy from the lesion on the eyelid.
Laboratory tests including serum vitamin D, thyroid and parathyroid hormone, calcium, phosphorus, and urinary calcium levels, as well as renal function tests, were within reference range. On the basis of these clinical and histopathological findings, the patient was diagnosed with MICC and palpebral syringoma.
Many dermatoses associated with DS have been reported including elastosis perforans serpiginosa, alopecia areata, and syringomas.1-3 Sano et al4 first described MICC and syringomas in a patient with DS in 1978. Milialike idiopathic calcinosis cutis is characterized by asymptomatic, millimetric, firm, round, whitish papules that are sometimes surrounded by erythema. These papules may show perforation leading to transepidermal elimination of calcium, similar to the transdermal elimination of elastic fibrils in elastosis perforans serpiginosa. Although MICC usually is described in acral sites of children with DS, it also is reported in adults without DS and on other parts of the body.5-7
The cause of MICC is unknown. One hypothesis of the development of MICC is an increase of the calcium content in the sweat leading to calcification of the acrosyringium.8 Milia are small keratin cysts that usually develop by occlusion of the hair follicle, sweat duct, or sebaceous duct. However, milia also can occur from occlusion of the eccrine ducts where syringomas originate.9 Therefore, syringomas can be seen in association with milia and calcium deposits.5,9-11
We believe that MICC in DS may be more common than usually recognized, as the lesions often are asymptomatic. It is important to differentiate MICC from other dermatological diseases such as molluscum contagiosum, verruca plana, milia, and inclusion cysts. Histopathology and dermoscopy could aid in the accurate diagnosis of MICC.
- Dourmishev A, Miteva L, Mitev V, et al. Cutaneous aspects of Down syndrome. Cutis. 2000;66:420-424.
- Madan V, Williams J, Lear JT. Dermatological manifestations of Down's syndrome. Clin Exp Dermatol. 2006;31:623-629.
- Schepis C, Barone C, Siragusa M, et al. An updated survey on skin conditions in Down syndrome. Dermatology. 2002;205:234-238.
- Sano T, Tate S, Ishikawa C. A case of Down's syndrome associated with syringoma, milia, and subepidermal calcified nodule. Jpn J Dermatol. 1978;88:740.
- Schepis C, Siragusa M, Palazzo R, et al. Perforating milia-like idiopathic calcinosis cutis and periorbital syringomas in a girl with Down syndrome. Pediatr Dermatol. 1994;11:258-260.
- Schepis C, Siragusa M, Palazzo R, et al. Milia like idiopathic calcinosis cutis: an unusual dermatosis associated with Down syndrome. Br J Dermatol. 1996;134:143-146.
- Houtappel M, Leguit R, Sigurdsson V. Milia-like idiopathic calcinosis cutis in an adult without Down's syndrome. J Dermatol Case Rep. 2007;1:16-19.
- Eng AM, Mandrea E. Perforating calcinosis cutis presenting as milia. J Cutan Pathol. 1981;8:247-250.
- Wang KH, Chu JS, Lin YH, et al. Milium-like syringoma: a case study on histogenesis. J Cutan Pathol. 2004;31:336-340.
- Weiss E, Paez E, Greenberg AS, et al. Eruptive syringomas associated with milia. Int J Dermatol. 1995;34:193-195.
- Kim SJ, Won YH, Chun IK. Subepidermal calcified nodules and syringoma. J Eur Acad Dermatol Venereol. 1997;8:51-52.
To the Editor:
Down syndrome (DS) is associated with rare dermatological disorders, and the prevalence of some common dermatoses is greater in patients with DS. We report a case of milialike idiopathic calcinosis cutis (MICC) associated with syringomas in a patient with DS. We emphasize that MICC is one of the rare dermatoses associated with DS.
A 4-year-old girl with DS presented with a 4-mm, flesh-colored, regular-bordered, exophytic papular lesion on the left upper eyelid of 8 months' duration (Figure 1). It was clinically recognized as syringoma. On dermatologic examination of the patient, there also were 1- to 3-mm, round, whitish, painless, milialike papules on the dorsal surface of the hands and wrists (Figure 2). Some of these papules were surrounded by erythema. There was no sign of perforation. Her personal and family history were unremarkable.
Histopathologic examination of a biopsy from a milialike lesion on the hand showed a hyperkeratotic epidermis. In the dermis there was a roundish calcific nodule surrounded by a fibrovascular rim. The patient's guardians refused a biopsy from the lesion on the eyelid.
Laboratory tests including serum vitamin D, thyroid and parathyroid hormone, calcium, phosphorus, and urinary calcium levels, as well as renal function tests, were within reference range. On the basis of these clinical and histopathological findings, the patient was diagnosed with MICC and palpebral syringoma.
Many dermatoses associated with DS have been reported including elastosis perforans serpiginosa, alopecia areata, and syringomas.1-3 Sano et al4 first described MICC and syringomas in a patient with DS in 1978. Milialike idiopathic calcinosis cutis is characterized by asymptomatic, millimetric, firm, round, whitish papules that are sometimes surrounded by erythema. These papules may show perforation leading to transepidermal elimination of calcium, similar to the transdermal elimination of elastic fibrils in elastosis perforans serpiginosa. Although MICC usually is described in acral sites of children with DS, it also is reported in adults without DS and on other parts of the body.5-7
The cause of MICC is unknown. One hypothesis of the development of MICC is an increase of the calcium content in the sweat leading to calcification of the acrosyringium.8 Milia are small keratin cysts that usually develop by occlusion of the hair follicle, sweat duct, or sebaceous duct. However, milia also can occur from occlusion of the eccrine ducts where syringomas originate.9 Therefore, syringomas can be seen in association with milia and calcium deposits.5,9-11
We believe that MICC in DS may be more common than usually recognized, as the lesions often are asymptomatic. It is important to differentiate MICC from other dermatological diseases such as molluscum contagiosum, verruca plana, milia, and inclusion cysts. Histopathology and dermoscopy could aid in the accurate diagnosis of MICC.
To the Editor:
Down syndrome (DS) is associated with rare dermatological disorders, and the prevalence of some common dermatoses is greater in patients with DS. We report a case of milialike idiopathic calcinosis cutis (MICC) associated with syringomas in a patient with DS. We emphasize that MICC is one of the rare dermatoses associated with DS.
A 4-year-old girl with DS presented with a 4-mm, flesh-colored, regular-bordered, exophytic papular lesion on the left upper eyelid of 8 months' duration (Figure 1). It was clinically recognized as syringoma. On dermatologic examination of the patient, there also were 1- to 3-mm, round, whitish, painless, milialike papules on the dorsal surface of the hands and wrists (Figure 2). Some of these papules were surrounded by erythema. There was no sign of perforation. Her personal and family history were unremarkable.
Histopathologic examination of a biopsy from a milialike lesion on the hand showed a hyperkeratotic epidermis. In the dermis there was a roundish calcific nodule surrounded by a fibrovascular rim. The patient's guardians refused a biopsy from the lesion on the eyelid.
Laboratory tests including serum vitamin D, thyroid and parathyroid hormone, calcium, phosphorus, and urinary calcium levels, as well as renal function tests, were within reference range. On the basis of these clinical and histopathological findings, the patient was diagnosed with MICC and palpebral syringoma.
Many dermatoses associated with DS have been reported including elastosis perforans serpiginosa, alopecia areata, and syringomas.1-3 Sano et al4 first described MICC and syringomas in a patient with DS in 1978. Milialike idiopathic calcinosis cutis is characterized by asymptomatic, millimetric, firm, round, whitish papules that are sometimes surrounded by erythema. These papules may show perforation leading to transepidermal elimination of calcium, similar to the transdermal elimination of elastic fibrils in elastosis perforans serpiginosa. Although MICC usually is described in acral sites of children with DS, it also is reported in adults without DS and on other parts of the body.5-7
The cause of MICC is unknown. One hypothesis of the development of MICC is an increase of the calcium content in the sweat leading to calcification of the acrosyringium.8 Milia are small keratin cysts that usually develop by occlusion of the hair follicle, sweat duct, or sebaceous duct. However, milia also can occur from occlusion of the eccrine ducts where syringomas originate.9 Therefore, syringomas can be seen in association with milia and calcium deposits.5,9-11
We believe that MICC in DS may be more common than usually recognized, as the lesions often are asymptomatic. It is important to differentiate MICC from other dermatological diseases such as molluscum contagiosum, verruca plana, milia, and inclusion cysts. Histopathology and dermoscopy could aid in the accurate diagnosis of MICC.
- Dourmishev A, Miteva L, Mitev V, et al. Cutaneous aspects of Down syndrome. Cutis. 2000;66:420-424.
- Madan V, Williams J, Lear JT. Dermatological manifestations of Down's syndrome. Clin Exp Dermatol. 2006;31:623-629.
- Schepis C, Barone C, Siragusa M, et al. An updated survey on skin conditions in Down syndrome. Dermatology. 2002;205:234-238.
- Sano T, Tate S, Ishikawa C. A case of Down's syndrome associated with syringoma, milia, and subepidermal calcified nodule. Jpn J Dermatol. 1978;88:740.
- Schepis C, Siragusa M, Palazzo R, et al. Perforating milia-like idiopathic calcinosis cutis and periorbital syringomas in a girl with Down syndrome. Pediatr Dermatol. 1994;11:258-260.
- Schepis C, Siragusa M, Palazzo R, et al. Milia like idiopathic calcinosis cutis: an unusual dermatosis associated with Down syndrome. Br J Dermatol. 1996;134:143-146.
- Houtappel M, Leguit R, Sigurdsson V. Milia-like idiopathic calcinosis cutis in an adult without Down's syndrome. J Dermatol Case Rep. 2007;1:16-19.
- Eng AM, Mandrea E. Perforating calcinosis cutis presenting as milia. J Cutan Pathol. 1981;8:247-250.
- Wang KH, Chu JS, Lin YH, et al. Milium-like syringoma: a case study on histogenesis. J Cutan Pathol. 2004;31:336-340.
- Weiss E, Paez E, Greenberg AS, et al. Eruptive syringomas associated with milia. Int J Dermatol. 1995;34:193-195.
- Kim SJ, Won YH, Chun IK. Subepidermal calcified nodules and syringoma. J Eur Acad Dermatol Venereol. 1997;8:51-52.
- Dourmishev A, Miteva L, Mitev V, et al. Cutaneous aspects of Down syndrome. Cutis. 2000;66:420-424.
- Madan V, Williams J, Lear JT. Dermatological manifestations of Down's syndrome. Clin Exp Dermatol. 2006;31:623-629.
- Schepis C, Barone C, Siragusa M, et al. An updated survey on skin conditions in Down syndrome. Dermatology. 2002;205:234-238.
- Sano T, Tate S, Ishikawa C. A case of Down's syndrome associated with syringoma, milia, and subepidermal calcified nodule. Jpn J Dermatol. 1978;88:740.
- Schepis C, Siragusa M, Palazzo R, et al. Perforating milia-like idiopathic calcinosis cutis and periorbital syringomas in a girl with Down syndrome. Pediatr Dermatol. 1994;11:258-260.
- Schepis C, Siragusa M, Palazzo R, et al. Milia like idiopathic calcinosis cutis: an unusual dermatosis associated with Down syndrome. Br J Dermatol. 1996;134:143-146.
- Houtappel M, Leguit R, Sigurdsson V. Milia-like idiopathic calcinosis cutis in an adult without Down's syndrome. J Dermatol Case Rep. 2007;1:16-19.
- Eng AM, Mandrea E. Perforating calcinosis cutis presenting as milia. J Cutan Pathol. 1981;8:247-250.
- Wang KH, Chu JS, Lin YH, et al. Milium-like syringoma: a case study on histogenesis. J Cutan Pathol. 2004;31:336-340.
- Weiss E, Paez E, Greenberg AS, et al. Eruptive syringomas associated with milia. Int J Dermatol. 1995;34:193-195.
- Kim SJ, Won YH, Chun IK. Subepidermal calcified nodules and syringoma. J Eur Acad Dermatol Venereol. 1997;8:51-52.
Practice Points
- Down syndrome is associated with rare dermatological disorders and an increased prevalence of common dermatoses.
- It is important to differentiate milialike idiopathic calcinosis cutis from other dermatological diseases using histopathology and dermoscopy.
Yoga may improve QOL in kids with cancer
Photo by Bill Branson
A yoga program for children with cancer can be carried out during cancer treatment and has quality of life (QOL) benefits for the children as well as their caregivers, according to research published in Rehabilitation Oncology.
However, the program was not feasible for all patients. More than half of those initially enrolled could not complete the study due to treatment toxicity or scheduling conflicts.
Andrea Orsey, MD, of Connecticut Children’s Medical Center in Hartford, and her colleagues conducted this research to evaluate the feasibility and effectiveness of a yoga intervention for children with cancer and their families.
The team began by conducting a survey of 20 children and adolescents with cancer and their parents/guardians.
Survey respondents expressed interest in a yoga program. But they also perceived several barriers to such a program, including concerns about side effects, pain/discomfort, and physical limitations.
With these barriers in mind, Dr Orsey and her colleagues developed a yoga intervention for pediatric cancer patients, delivered by certified yoga instructors.
The program was designed to be performed in a variety of settings and tailored to the children’s physical condition or mobility issues.
A pilot evaluation included 10 children with cancer and their caregivers. Twenty-two patient/caregiver pairs were actually enrolled, but 6 pairs withdrew because of treatment toxicity, and 6 had the study window lapse due to scheduling conflicts.
Although limited by its small size, the study suggested that yoga improved health-related QOL for both caregivers and children.
The children had significant improvements in both social and emotional QOL. They had an overall improvement in fatigue, but this was not statistically significant.
Caregivers had a significant improvement in mental health but not physical health or caregiver burden.
Both caregivers and children said they were satisfied with the yoga program and would recommend it to others.
Dr Orsey and her colleagues hope this pilot study will help guide future efforts to provide yoga to children with cancer and their families.
The researchers noted that a key issue will be coordinating yoga sessions with the medical demands of chemotherapy. 
Photo by Bill Branson
A yoga program for children with cancer can be carried out during cancer treatment and has quality of life (QOL) benefits for the children as well as their caregivers, according to research published in Rehabilitation Oncology.
However, the program was not feasible for all patients. More than half of those initially enrolled could not complete the study due to treatment toxicity or scheduling conflicts.
Andrea Orsey, MD, of Connecticut Children’s Medical Center in Hartford, and her colleagues conducted this research to evaluate the feasibility and effectiveness of a yoga intervention for children with cancer and their families.
The team began by conducting a survey of 20 children and adolescents with cancer and their parents/guardians.
Survey respondents expressed interest in a yoga program. But they also perceived several barriers to such a program, including concerns about side effects, pain/discomfort, and physical limitations.
With these barriers in mind, Dr Orsey and her colleagues developed a yoga intervention for pediatric cancer patients, delivered by certified yoga instructors.
The program was designed to be performed in a variety of settings and tailored to the children’s physical condition or mobility issues.
A pilot evaluation included 10 children with cancer and their caregivers. Twenty-two patient/caregiver pairs were actually enrolled, but 6 pairs withdrew because of treatment toxicity, and 6 had the study window lapse due to scheduling conflicts.
Although limited by its small size, the study suggested that yoga improved health-related QOL for both caregivers and children.
The children had significant improvements in both social and emotional QOL. They had an overall improvement in fatigue, but this was not statistically significant.
Caregivers had a significant improvement in mental health but not physical health or caregiver burden.
Both caregivers and children said they were satisfied with the yoga program and would recommend it to others.
Dr Orsey and her colleagues hope this pilot study will help guide future efforts to provide yoga to children with cancer and their families.
The researchers noted that a key issue will be coordinating yoga sessions with the medical demands of chemotherapy.
Photo by Bill Branson
A yoga program for children with cancer can be carried out during cancer treatment and has quality of life (QOL) benefits for the children as well as their caregivers, according to research published in Rehabilitation Oncology.
However, the program was not feasible for all patients. More than half of those initially enrolled could not complete the study due to treatment toxicity or scheduling conflicts.
Andrea Orsey, MD, of Connecticut Children’s Medical Center in Hartford, and her colleagues conducted this research to evaluate the feasibility and effectiveness of a yoga intervention for children with cancer and their families.
The team began by conducting a survey of 20 children and adolescents with cancer and their parents/guardians.
Survey respondents expressed interest in a yoga program. But they also perceived several barriers to such a program, including concerns about side effects, pain/discomfort, and physical limitations.
With these barriers in mind, Dr Orsey and her colleagues developed a yoga intervention for pediatric cancer patients, delivered by certified yoga instructors.
The program was designed to be performed in a variety of settings and tailored to the children’s physical condition or mobility issues.
A pilot evaluation included 10 children with cancer and their caregivers. Twenty-two patient/caregiver pairs were actually enrolled, but 6 pairs withdrew because of treatment toxicity, and 6 had the study window lapse due to scheduling conflicts.
Although limited by its small size, the study suggested that yoga improved health-related QOL for both caregivers and children.
The children had significant improvements in both social and emotional QOL. They had an overall improvement in fatigue, but this was not statistically significant.
Caregivers had a significant improvement in mental health but not physical health or caregiver burden.
Both caregivers and children said they were satisfied with the yoga program and would recommend it to others.
Dr Orsey and her colleagues hope this pilot study will help guide future efforts to provide yoga to children with cancer and their families.
The researchers noted that a key issue will be coordinating yoga sessions with the medical demands of chemotherapy.
Transient Benign Neonatal Skin Findings
Review the PDF of the fact sheet on transient benign neonatal skin findings with board-relevant, easy-to-review material. This fact sheet lists benign findings that can be seen in neonates and infants.
Practice Questions
1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?
a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily
2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?
a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized
3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?
a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin
4. Which intraoral cysts occur on the alveolar ridge of a neonate?
a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn
5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?
a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis
Answers to practice questions provided on next page
Practice Question Answers
1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?
a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily
2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?
a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized
3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?
a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin
4. Which intraoral cysts occur on the alveolar ridge of a neonate?
a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn
5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?
a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis
Review the PDF of the fact sheet on transient benign neonatal skin findings with board-relevant, easy-to-review material. This fact sheet lists benign findings that can be seen in neonates and infants.
Practice Questions
1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?
a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily
2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?
a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized
3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?
a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin
4. Which intraoral cysts occur on the alveolar ridge of a neonate?
a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn
5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?
a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis
Answers to practice questions provided on next page
Practice Question Answers
1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?
a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily
2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?
a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized
3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?
a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin
4. Which intraoral cysts occur on the alveolar ridge of a neonate?
a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn
5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?
a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis
Review the PDF of the fact sheet on transient benign neonatal skin findings with board-relevant, easy-to-review material. This fact sheet lists benign findings that can be seen in neonates and infants.
Practice Questions
1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?
a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily
2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?
a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized
3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?
a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin
4. Which intraoral cysts occur on the alveolar ridge of a neonate?
a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn
5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?
a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis
Answers to practice questions provided on next page
Practice Question Answers
1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?
a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily
2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?
a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized
3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?
a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin
4. Which intraoral cysts occur on the alveolar ridge of a neonate?
a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn
5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?
a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis
ACL injuries: Why are teen females at greater risk?
Over the last 2 decades, the number of teen females involved in competitive sports has skyrocketed. Research studies continue to show that girls involved in sports have better self-esteem and reduce the risk of obesity.But this involvement in competitive sports has not come without a cost. Recent studies have shown that females are four to six times more likely to tear their anterior cruciate ligament (ACL) than are their male counterparts playing the same sport.1,2 But why is this? And can it be prevented?
Researchers have spent countless hours studying videos to better determine why females are at greater risk. Their findings showed that there were many contributing factors for the difference between the sexes. The general mechanics that put the ACL at risk are landing on an extended knee, the center of mass being off the base, and internal rotation and adduction of the knee. These combined movements put the ACL at its most vulnerable position.
Hormones are another contributing factor. Estrogen and relaxin give strength and flexibility to the ligaments. But during surges of these hormones – such as during menses or a growth spurt – there is laxity within the ligament, putting it at further risk of injury.1 Testosterone increases muscle mass and strength. For males, this is protective because they rely less on their ligaments during jumping and deceleration. Puberty also contributes to the increased risk by accelerating the body mass index quickly over a short period, and therefore, greater strength is needed.1,3
Core strength, which helps with balance, is another contributing factor. Females tend to have lower core strength, which puts them at greater risk for rotational forces, especially when landing on one foot.1,4 As core strength improves, athletes can change direction more efficiently and hold their bodies upright on a single limb, which prevents the torsion that contributes to injury.
Prevention for ACL injuries occurs through very specific training in repetitive jumping and balance exercises are known as plyometric exercises. Neuromuscular training (NMT) includes plyometric training along with strengthening exercises such as lunges, squats, and plank exercises.4 One can reduce the risk of injury by 72% with 6-8 weeks of training by a professional experienced in NMT.5
Educating parents on the increased risk of injury to the ACL in females and importance of proper training can reduce injury and the risk of degenerative joint disease in later years.6 The Institute for Sports Medicine has a website that offers a knee injury prevention program you can refer families to for more information to prevent knee injuries. Sportsmetrics can help locate an NMT professional near them. Knowledge is power!
Reference
1. Pediatrics. 2014 May;133(5):e1437-50
2. Bull Hosp Jt Dis. 2000;59(4):217-26
3. Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1060-6
4. Am J Phys Med Rehabil. 2005 Feb;84(2):122-30
5. Am J Sports Med. 2008 Aug;36(8):1476-83
6. Curr Womens Health Rep. 2001 Dec;1(3):218-24
Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at pdnews@frontlinemedcom.com.
Over the last 2 decades, the number of teen females involved in competitive sports has skyrocketed. Research studies continue to show that girls involved in sports have better self-esteem and reduce the risk of obesity.But this involvement in competitive sports has not come without a cost. Recent studies have shown that females are four to six times more likely to tear their anterior cruciate ligament (ACL) than are their male counterparts playing the same sport.1,2 But why is this? And can it be prevented?
Researchers have spent countless hours studying videos to better determine why females are at greater risk. Their findings showed that there were many contributing factors for the difference between the sexes. The general mechanics that put the ACL at risk are landing on an extended knee, the center of mass being off the base, and internal rotation and adduction of the knee. These combined movements put the ACL at its most vulnerable position.
Hormones are another contributing factor. Estrogen and relaxin give strength and flexibility to the ligaments. But during surges of these hormones – such as during menses or a growth spurt – there is laxity within the ligament, putting it at further risk of injury.1 Testosterone increases muscle mass and strength. For males, this is protective because they rely less on their ligaments during jumping and deceleration. Puberty also contributes to the increased risk by accelerating the body mass index quickly over a short period, and therefore, greater strength is needed.1,3
Core strength, which helps with balance, is another contributing factor. Females tend to have lower core strength, which puts them at greater risk for rotational forces, especially when landing on one foot.1,4 As core strength improves, athletes can change direction more efficiently and hold their bodies upright on a single limb, which prevents the torsion that contributes to injury.
Prevention for ACL injuries occurs through very specific training in repetitive jumping and balance exercises are known as plyometric exercises. Neuromuscular training (NMT) includes plyometric training along with strengthening exercises such as lunges, squats, and plank exercises.4 One can reduce the risk of injury by 72% with 6-8 weeks of training by a professional experienced in NMT.5
Educating parents on the increased risk of injury to the ACL in females and importance of proper training can reduce injury and the risk of degenerative joint disease in later years.6 The Institute for Sports Medicine has a website that offers a knee injury prevention program you can refer families to for more information to prevent knee injuries. Sportsmetrics can help locate an NMT professional near them. Knowledge is power!
Reference
1. Pediatrics. 2014 May;133(5):e1437-50
2. Bull Hosp Jt Dis. 2000;59(4):217-26
3. Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1060-6
4. Am J Phys Med Rehabil. 2005 Feb;84(2):122-30
5. Am J Sports Med. 2008 Aug;36(8):1476-83
6. Curr Womens Health Rep. 2001 Dec;1(3):218-24
Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at pdnews@frontlinemedcom.com.
Over the last 2 decades, the number of teen females involved in competitive sports has skyrocketed. Research studies continue to show that girls involved in sports have better self-esteem and reduce the risk of obesity.But this involvement in competitive sports has not come without a cost. Recent studies have shown that females are four to six times more likely to tear their anterior cruciate ligament (ACL) than are their male counterparts playing the same sport.1,2 But why is this? And can it be prevented?
Researchers have spent countless hours studying videos to better determine why females are at greater risk. Their findings showed that there were many contributing factors for the difference between the sexes. The general mechanics that put the ACL at risk are landing on an extended knee, the center of mass being off the base, and internal rotation and adduction of the knee. These combined movements put the ACL at its most vulnerable position.
Hormones are another contributing factor. Estrogen and relaxin give strength and flexibility to the ligaments. But during surges of these hormones – such as during menses or a growth spurt – there is laxity within the ligament, putting it at further risk of injury.1 Testosterone increases muscle mass and strength. For males, this is protective because they rely less on their ligaments during jumping and deceleration. Puberty also contributes to the increased risk by accelerating the body mass index quickly over a short period, and therefore, greater strength is needed.1,3
Core strength, which helps with balance, is another contributing factor. Females tend to have lower core strength, which puts them at greater risk for rotational forces, especially when landing on one foot.1,4 As core strength improves, athletes can change direction more efficiently and hold their bodies upright on a single limb, which prevents the torsion that contributes to injury.
Prevention for ACL injuries occurs through very specific training in repetitive jumping and balance exercises are known as plyometric exercises. Neuromuscular training (NMT) includes plyometric training along with strengthening exercises such as lunges, squats, and plank exercises.4 One can reduce the risk of injury by 72% with 6-8 weeks of training by a professional experienced in NMT.5
Educating parents on the increased risk of injury to the ACL in females and importance of proper training can reduce injury and the risk of degenerative joint disease in later years.6 The Institute for Sports Medicine has a website that offers a knee injury prevention program you can refer families to for more information to prevent knee injuries. Sportsmetrics can help locate an NMT professional near them. Knowledge is power!
Reference
1. Pediatrics. 2014 May;133(5):e1437-50
2. Bull Hosp Jt Dis. 2000;59(4):217-26
3. Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1060-6
4. Am J Phys Med Rehabil. 2005 Feb;84(2):122-30
5. Am J Sports Med. 2008 Aug;36(8):1476-83
6. Curr Womens Health Rep. 2001 Dec;1(3):218-24
Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at pdnews@frontlinemedcom.com.
VIDEO: ECG screen for cardiac disease in all youths is cost effective
NEW ORLEANS – Results of a first-of-its-kind nationwide U.K. cardiac disease screening program in the general population of teens and young adults indicate that incorporating a 12-lead ECG alongside history and physical examination not only increases the diagnostic yield for conditions predisposing to sudden cardiac death, but it’s actually cost saving, compared with screening by history and physical exam alone, Harshil Dhutia, MD, said at the American Heart Association scientific sessions.
Current practice in the United Kingdom and most other western countries, including the United States, is to screen for cardiac disease in the general population of young people by history and physical exam alone. Only those with symptoms or a positive family history on the initial screen go on to a more comprehensive evaluation including an ECG. The ECG isn’t part of the initial screen primarily because of cost concerns. However, those concerns are based upon conjecture. The diagnostic and financial implications of routine screening by 12-lead ECG in the general population of young people hadn’t been examined prior to the nationwide U.K. screening program – and the results of the U.K. project indicate it’s time for a change in policy, according to Dr. Dhutia, a cardiology research fellow at St. George’s University in London.
The screening project, known as the Cardiac Risk in the Young Program, included 26,900 subjects aged 14-35 years without known cardiovascular disease who responded to public service announcements and voluntarily presented for screening at schools, community centers, and health centers across the U.K. during 2011-2013. The mean age of the subjects was 19.4 years, roughly two-thirds were male, and 90% were white. All screening was performed by cardiologists who followed the AHA protocol for history-taking, performed the physical exam, and followed the European Society of Cardiology 2010 recommendations for ECG interpretation. Individuals with a positive screen were referred to their local hospital for further investigation. Participants were prospectively followed for 2 years.
“This was the first study of comprehensive cardiovascular screening of young individuals outside competitive sport,” Dr. Dhutia noted.
Among the key findings: 3.5% of subjects were deemed by their screening cardiologist to have an abnormal history and/or physical exam warranting further investigation, 8.1% had an abnormal 12-lead ECG, and 0.5% had both. Overall, 11.7% of subjects underwent echocardiography to confirm or refute a diagnosis of cardiac disease, 1.7% underwent Holter monitoring, 1.7% had an exercise stress test, and 0.9% underwent cardiac MRI.
At 2 years of follow-up, 87 individuals, or 0.3% of the overall study cohort, had been diagnosed with a serious cardiac disease predisposing to sudden cardiac death.
“The vast majority of these individuals were asymptomatic and diagnosed on the basis of an ECG abnormality,” Dr. Dhutia observed.
Indeed, 72 of the 87 patients with serious cardiac disease were diagnosed on the basis on their abnormal ECG. This tool proved particularly helpful in identifying individuals with cardiomyopathies or congenital accessory pathways, such as Wolff-Parkinson-White syndrome or long QT syndrome. At 2 years of follow-up, 42 of these 72 patients were on disease-modifying therapies beyond lifestyle interventions, most commonly ablation procedures or antiarrhythmic medication.
The history and physical exam was useful in identifying young people with channelopathies or Marfan syndrome. Roughly half of individuals identified by history and physical exam as having serious cardiac disease were on antiarrhythmic medication – or, less commonly, pacemaker therapy – at 2 years follow-up.
The overall cost per individual screened using history, physical exam, and ECG amounted to $110 on the basis of U.K. National Health Service rates. The cost per serious cardiac condition identified was $33,927. In contrast, the average cost per serious cardiac diagnosis under the current U.K. protocol of screening youth by history and physical exam only is 67% greater, at $56,597.
“Inclusion of ECG to history and physical examination is associated with a significantly improved diagnostic yield and superior economic profile. These findings have the potential to influence health care policy and certainly suggest that the National Health Service framework in the United Kingdom is counterintuitive and may warrant revision,” he concluded.
Session moderator Nisha Parikh, MD, of the University of California, San Francisco, asked if Dr. Dhutia and his coinvestigators had identified any characteristics associated with serious occult cardiac disease in adolescents and young adults that would permit a more refined, selective approach to screening.
Not in the general population of nearly 27,000 subjects in the U.K. study, he replied. Competitive athletes are a different story, though.
“In competitive athletes, certainly individuals who play stop/start sports such as basketball or football [soccer], appear to be at higher risk, especially those of Afro-Caribbean origin. The incidence of sudden cardiac death in Afro-Caribbean basketball players is 1 in 3,000,” according to Dr. Dhutia, who discussed his findings in a video interview.
He reported receiving a small research grant for his study from the Cardiac Risk in the Young Program, a U.K. charitable organization.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NEW ORLEANS – Results of a first-of-its-kind nationwide U.K. cardiac disease screening program in the general population of teens and young adults indicate that incorporating a 12-lead ECG alongside history and physical examination not only increases the diagnostic yield for conditions predisposing to sudden cardiac death, but it’s actually cost saving, compared with screening by history and physical exam alone, Harshil Dhutia, MD, said at the American Heart Association scientific sessions.
Current practice in the United Kingdom and most other western countries, including the United States, is to screen for cardiac disease in the general population of young people by history and physical exam alone. Only those with symptoms or a positive family history on the initial screen go on to a more comprehensive evaluation including an ECG. The ECG isn’t part of the initial screen primarily because of cost concerns. However, those concerns are based upon conjecture. The diagnostic and financial implications of routine screening by 12-lead ECG in the general population of young people hadn’t been examined prior to the nationwide U.K. screening program – and the results of the U.K. project indicate it’s time for a change in policy, according to Dr. Dhutia, a cardiology research fellow at St. George’s University in London.
The screening project, known as the Cardiac Risk in the Young Program, included 26,900 subjects aged 14-35 years without known cardiovascular disease who responded to public service announcements and voluntarily presented for screening at schools, community centers, and health centers across the U.K. during 2011-2013. The mean age of the subjects was 19.4 years, roughly two-thirds were male, and 90% were white. All screening was performed by cardiologists who followed the AHA protocol for history-taking, performed the physical exam, and followed the European Society of Cardiology 2010 recommendations for ECG interpretation. Individuals with a positive screen were referred to their local hospital for further investigation. Participants were prospectively followed for 2 years.
“This was the first study of comprehensive cardiovascular screening of young individuals outside competitive sport,” Dr. Dhutia noted.
Among the key findings: 3.5% of subjects were deemed by their screening cardiologist to have an abnormal history and/or physical exam warranting further investigation, 8.1% had an abnormal 12-lead ECG, and 0.5% had both. Overall, 11.7% of subjects underwent echocardiography to confirm or refute a diagnosis of cardiac disease, 1.7% underwent Holter monitoring, 1.7% had an exercise stress test, and 0.9% underwent cardiac MRI.
At 2 years of follow-up, 87 individuals, or 0.3% of the overall study cohort, had been diagnosed with a serious cardiac disease predisposing to sudden cardiac death.
“The vast majority of these individuals were asymptomatic and diagnosed on the basis of an ECG abnormality,” Dr. Dhutia observed.
Indeed, 72 of the 87 patients with serious cardiac disease were diagnosed on the basis on their abnormal ECG. This tool proved particularly helpful in identifying individuals with cardiomyopathies or congenital accessory pathways, such as Wolff-Parkinson-White syndrome or long QT syndrome. At 2 years of follow-up, 42 of these 72 patients were on disease-modifying therapies beyond lifestyle interventions, most commonly ablation procedures or antiarrhythmic medication.
The history and physical exam was useful in identifying young people with channelopathies or Marfan syndrome. Roughly half of individuals identified by history and physical exam as having serious cardiac disease were on antiarrhythmic medication – or, less commonly, pacemaker therapy – at 2 years follow-up.
The overall cost per individual screened using history, physical exam, and ECG amounted to $110 on the basis of U.K. National Health Service rates. The cost per serious cardiac condition identified was $33,927. In contrast, the average cost per serious cardiac diagnosis under the current U.K. protocol of screening youth by history and physical exam only is 67% greater, at $56,597.
“Inclusion of ECG to history and physical examination is associated with a significantly improved diagnostic yield and superior economic profile. These findings have the potential to influence health care policy and certainly suggest that the National Health Service framework in the United Kingdom is counterintuitive and may warrant revision,” he concluded.
Session moderator Nisha Parikh, MD, of the University of California, San Francisco, asked if Dr. Dhutia and his coinvestigators had identified any characteristics associated with serious occult cardiac disease in adolescents and young adults that would permit a more refined, selective approach to screening.
Not in the general population of nearly 27,000 subjects in the U.K. study, he replied. Competitive athletes are a different story, though.
“In competitive athletes, certainly individuals who play stop/start sports such as basketball or football [soccer], appear to be at higher risk, especially those of Afro-Caribbean origin. The incidence of sudden cardiac death in Afro-Caribbean basketball players is 1 in 3,000,” according to Dr. Dhutia, who discussed his findings in a video interview.
He reported receiving a small research grant for his study from the Cardiac Risk in the Young Program, a U.K. charitable organization.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NEW ORLEANS – Results of a first-of-its-kind nationwide U.K. cardiac disease screening program in the general population of teens and young adults indicate that incorporating a 12-lead ECG alongside history and physical examination not only increases the diagnostic yield for conditions predisposing to sudden cardiac death, but it’s actually cost saving, compared with screening by history and physical exam alone, Harshil Dhutia, MD, said at the American Heart Association scientific sessions.
Current practice in the United Kingdom and most other western countries, including the United States, is to screen for cardiac disease in the general population of young people by history and physical exam alone. Only those with symptoms or a positive family history on the initial screen go on to a more comprehensive evaluation including an ECG. The ECG isn’t part of the initial screen primarily because of cost concerns. However, those concerns are based upon conjecture. The diagnostic and financial implications of routine screening by 12-lead ECG in the general population of young people hadn’t been examined prior to the nationwide U.K. screening program – and the results of the U.K. project indicate it’s time for a change in policy, according to Dr. Dhutia, a cardiology research fellow at St. George’s University in London.
The screening project, known as the Cardiac Risk in the Young Program, included 26,900 subjects aged 14-35 years without known cardiovascular disease who responded to public service announcements and voluntarily presented for screening at schools, community centers, and health centers across the U.K. during 2011-2013. The mean age of the subjects was 19.4 years, roughly two-thirds were male, and 90% were white. All screening was performed by cardiologists who followed the AHA protocol for history-taking, performed the physical exam, and followed the European Society of Cardiology 2010 recommendations for ECG interpretation. Individuals with a positive screen were referred to their local hospital for further investigation. Participants were prospectively followed for 2 years.
“This was the first study of comprehensive cardiovascular screening of young individuals outside competitive sport,” Dr. Dhutia noted.
Among the key findings: 3.5% of subjects were deemed by their screening cardiologist to have an abnormal history and/or physical exam warranting further investigation, 8.1% had an abnormal 12-lead ECG, and 0.5% had both. Overall, 11.7% of subjects underwent echocardiography to confirm or refute a diagnosis of cardiac disease, 1.7% underwent Holter monitoring, 1.7% had an exercise stress test, and 0.9% underwent cardiac MRI.
At 2 years of follow-up, 87 individuals, or 0.3% of the overall study cohort, had been diagnosed with a serious cardiac disease predisposing to sudden cardiac death.
“The vast majority of these individuals were asymptomatic and diagnosed on the basis of an ECG abnormality,” Dr. Dhutia observed.
Indeed, 72 of the 87 patients with serious cardiac disease were diagnosed on the basis on their abnormal ECG. This tool proved particularly helpful in identifying individuals with cardiomyopathies or congenital accessory pathways, such as Wolff-Parkinson-White syndrome or long QT syndrome. At 2 years of follow-up, 42 of these 72 patients were on disease-modifying therapies beyond lifestyle interventions, most commonly ablation procedures or antiarrhythmic medication.
The history and physical exam was useful in identifying young people with channelopathies or Marfan syndrome. Roughly half of individuals identified by history and physical exam as having serious cardiac disease were on antiarrhythmic medication – or, less commonly, pacemaker therapy – at 2 years follow-up.
The overall cost per individual screened using history, physical exam, and ECG amounted to $110 on the basis of U.K. National Health Service rates. The cost per serious cardiac condition identified was $33,927. In contrast, the average cost per serious cardiac diagnosis under the current U.K. protocol of screening youth by history and physical exam only is 67% greater, at $56,597.
“Inclusion of ECG to history and physical examination is associated with a significantly improved diagnostic yield and superior economic profile. These findings have the potential to influence health care policy and certainly suggest that the National Health Service framework in the United Kingdom is counterintuitive and may warrant revision,” he concluded.
Session moderator Nisha Parikh, MD, of the University of California, San Francisco, asked if Dr. Dhutia and his coinvestigators had identified any characteristics associated with serious occult cardiac disease in adolescents and young adults that would permit a more refined, selective approach to screening.
Not in the general population of nearly 27,000 subjects in the U.K. study, he replied. Competitive athletes are a different story, though.
“In competitive athletes, certainly individuals who play stop/start sports such as basketball or football [soccer], appear to be at higher risk, especially those of Afro-Caribbean origin. The incidence of sudden cardiac death in Afro-Caribbean basketball players is 1 in 3,000,” according to Dr. Dhutia, who discussed his findings in a video interview.
He reported receiving a small research grant for his study from the Cardiac Risk in the Young Program, a U.K. charitable organization.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Key clinical point:
Major finding: The cost of identifying one case of serious cardiac disease predisposing to sudden cardiac death in young people was reduced by 40% when initial screening of the general population ages 14-35 years was conducted by history, physical examination, and 12-lead ECG, compared with no ECG.
Data source: A prospective observational study of nearly 27,000 young people ages 14-35 years in the general population across the United Kingdom who presented for cardiac screening conducted by cardiologists using history, physical examination, and a 12-lead ECG.
Disclosures: The study was funded by the Cardiac Risk in the Young Program, a U.K. charitable organization.
Psychiatric comorbidities common in newly diagnosed pediatric epilepsy cases
HOUSTON – About one in three children diagnosed with new-onset epilepsy presents with psychiatric diagnoses at the onset, results from a single-center study showed.
The finding “tells us that when kids are coming in, even if they’re only having psychiatric symptoms at their onset of epilepsy, they should be referred for some treatment to help them possibly mitigate the development of these psychiatric diagnoses in the first year,” lead study author Julia Doss, PsyD, said in an interview at annual meeting of the American Epilepsy Society.
Dr. Doss, a clinical psychologist with Minnesota Epilepsy Group, and her associates divided the children into three groups: age 3-6 (group 1), age 7-11 (group 2), and age 12-18 (group 3). Based on the Clinical Interview, none of the patients in group 1 screened positive for depression or anxiety, but 16% met criteria for some other behavioral disorder. However, among patients in group 2, the percentage who met criteria for depression, anxiety, and other behavioral disorders was 13%, 25%, and 13%, respectively. The corresponding percentages for patients in group 3 were 29%, 38%, and 10%.
Of the 96 patients evaluated in the clinic, 64 parents completed all of the questions on the SDQ. The researchers observed significant correlations between parent response and diagnoses assigned on the Clinical Interview for behavior diagnoses (P = .002) and anxiety diagnoses (P = .009) but not for depression diagnoses. “Despite the correlations on both behavior and anxiety responses and clinical diagnoses assigned, parents still only reported significant concerns in about half of the children that were given diagnoses,” Dr. Doss and her associates wrote in their abstract.
The comparison of RCADS scores between parent and child demonstrated moderate to strong correlation with each other on the following scales: separation anxiety, generalized anxiety, obsessive/compulsive, and depression.
Dr. Doss cited the study’s small sample size as a key limitation. “Early evaluation or at least screening is necessary in all of our kids who present with an epilepsy diagnosis, because more than 30% develop psychiatric disorders within the first year of their diagnosis,” she concluded. “That’s one in three, so if we can start to better evaluate that early and get them funneled into treatment early, we might be able to prevent some of these problems from becoming lifelong issues.”
She reported having no financial disclosures.
HOUSTON – About one in three children diagnosed with new-onset epilepsy presents with psychiatric diagnoses at the onset, results from a single-center study showed.
The finding “tells us that when kids are coming in, even if they’re only having psychiatric symptoms at their onset of epilepsy, they should be referred for some treatment to help them possibly mitigate the development of these psychiatric diagnoses in the first year,” lead study author Julia Doss, PsyD, said in an interview at annual meeting of the American Epilepsy Society.
Dr. Doss, a clinical psychologist with Minnesota Epilepsy Group, and her associates divided the children into three groups: age 3-6 (group 1), age 7-11 (group 2), and age 12-18 (group 3). Based on the Clinical Interview, none of the patients in group 1 screened positive for depression or anxiety, but 16% met criteria for some other behavioral disorder. However, among patients in group 2, the percentage who met criteria for depression, anxiety, and other behavioral disorders was 13%, 25%, and 13%, respectively. The corresponding percentages for patients in group 3 were 29%, 38%, and 10%.
Of the 96 patients evaluated in the clinic, 64 parents completed all of the questions on the SDQ. The researchers observed significant correlations between parent response and diagnoses assigned on the Clinical Interview for behavior diagnoses (P = .002) and anxiety diagnoses (P = .009) but not for depression diagnoses. “Despite the correlations on both behavior and anxiety responses and clinical diagnoses assigned, parents still only reported significant concerns in about half of the children that were given diagnoses,” Dr. Doss and her associates wrote in their abstract.
The comparison of RCADS scores between parent and child demonstrated moderate to strong correlation with each other on the following scales: separation anxiety, generalized anxiety, obsessive/compulsive, and depression.
Dr. Doss cited the study’s small sample size as a key limitation. “Early evaluation or at least screening is necessary in all of our kids who present with an epilepsy diagnosis, because more than 30% develop psychiatric disorders within the first year of their diagnosis,” she concluded. “That’s one in three, so if we can start to better evaluate that early and get them funneled into treatment early, we might be able to prevent some of these problems from becoming lifelong issues.”
She reported having no financial disclosures.
HOUSTON – About one in three children diagnosed with new-onset epilepsy presents with psychiatric diagnoses at the onset, results from a single-center study showed.
The finding “tells us that when kids are coming in, even if they’re only having psychiatric symptoms at their onset of epilepsy, they should be referred for some treatment to help them possibly mitigate the development of these psychiatric diagnoses in the first year,” lead study author Julia Doss, PsyD, said in an interview at annual meeting of the American Epilepsy Society.
Dr. Doss, a clinical psychologist with Minnesota Epilepsy Group, and her associates divided the children into three groups: age 3-6 (group 1), age 7-11 (group 2), and age 12-18 (group 3). Based on the Clinical Interview, none of the patients in group 1 screened positive for depression or anxiety, but 16% met criteria for some other behavioral disorder. However, among patients in group 2, the percentage who met criteria for depression, anxiety, and other behavioral disorders was 13%, 25%, and 13%, respectively. The corresponding percentages for patients in group 3 were 29%, 38%, and 10%.
Of the 96 patients evaluated in the clinic, 64 parents completed all of the questions on the SDQ. The researchers observed significant correlations between parent response and diagnoses assigned on the Clinical Interview for behavior diagnoses (P = .002) and anxiety diagnoses (P = .009) but not for depression diagnoses. “Despite the correlations on both behavior and anxiety responses and clinical diagnoses assigned, parents still only reported significant concerns in about half of the children that were given diagnoses,” Dr. Doss and her associates wrote in their abstract.
The comparison of RCADS scores between parent and child demonstrated moderate to strong correlation with each other on the following scales: separation anxiety, generalized anxiety, obsessive/compulsive, and depression.
Dr. Doss cited the study’s small sample size as a key limitation. “Early evaluation or at least screening is necessary in all of our kids who present with an epilepsy diagnosis, because more than 30% develop psychiatric disorders within the first year of their diagnosis,” she concluded. “That’s one in three, so if we can start to better evaluate that early and get them funneled into treatment early, we might be able to prevent some of these problems from becoming lifelong issues.”
She reported having no financial disclosures.
Key clinical point:
Major finding: Among patients aged 12-18 years, the percentage who met criteria for criteria for depression, anxiety, and other behavioral disorders was 29%, 38%, and 10%, respectively.
Data source: A study of 96 patients who presented to a New Onset Pediatric Epilepsy (NOPE) clinic within 8 weeks of their epilepsy diagnosis.
Disclosures: Dr. Doss reported having no financial disclosures.
NIAID panel: Introduce peanut foods early to cut allergy risk
Introducing peanut foods to children who are at different levels of risk for peanut allergies may prevent or mitigate the risk, and the strategies for clinicians are explained in new addendum guidelines issued by an expert panel sponsored by the National Institute of Allergy and Infectious Diseases.
The guidelines were published online Jan. 5 in the Journal of Allergy and Clinical Immunology (J Allergy Clin Immunol. 2017. doi: 10.1016/j.jaci.2016.10.010).
“In the majority of patients, peanut allergy begins early in life and persists as a lifelong problem,” wrote lead author Alkis Togias, MD, of NIAID in Bethesda, Md., and colleagues. Previous guidelines published in 2010 did not provide specific treatment strategies for peanut allergies because of a lack of research, but the significant results of the Learning Early About Peanut Allergy (LEAP) study suggested that early exposure to peanut-containing foods reduces the risk of developing allergies. 
The NIAID’s Guidelines Coordinating Committee conducted a literature review covering research from January 2010 to June 2016 and developed addendum guidelines, as follows:
For infants with severe eczema, egg allergies, or both, peanut-containing foods should be introduced at 4-6 months of age at the earliest, after the introduction of other solid foods to confirm developmental readiness. If the infant is developmentally ready for solids, clinicians should “strongly consider” evaluation by peanut-specific IgE (peanut sIgE) measurement and/or skin prick test before introducing peanut products to determine the potential sensitivity and need for supervised feeding vs. feeding at home.
If dietary peanut will be introduced based on the recommendations, “the total amount of peanut protein to be regularly consumed per week should be approximately 6 to 7 g over 3 or more feedings,” the authors wrote.
However, children already identified as allergic to peanut should practice strict peanut avoidance, they added. In addition, they recommend that clinicians review risks and benefits for high-risk children who may have family members with established peanut allergies.
For infants with mild to moderate eczema, the recommendation is to introduce peanut-containing foods at approximately 6 months of age, “in accordance with family preferences and cultural practices,” after the introduction of other solid foods, to help reduce the risk of peanut allergies. The expert panel recommends that infants in this moderate-risk category may receive peanut foods at home without an office visit, although caregivers or clinicians may choose an office visit for supervised feeding, evaluation, or both. Although the LEAP trial did not target infants with mild or moderate eczema, the panel has no reason to believe that the protective mechanisms are different in these children.
For infants with no eczema or any food allergies, the guidelines recommend introducing peanut-containing foods at any age, as appropriate and in keeping with a family’s preferences and cultural practices.
“The early introduction of dietary peanut in children without risk factors for peanut allergy is generally anticipated to be safe and to contribute modestly to an overall reduction in the prevalence of peanut allergy,” the researchers said.
The findings of the LEAP and accompanying LEAP-On trials were so compelling (approximately 80% relative reduction in peanut allergy at 5 years of age for peanut-exposed children, compared with standard of care) that the NIAID and expert panel “felt it was necessary to review and revise the previous recommendations from the 2010 guidelines on the diagnosis and management of food allergy,” Hugh Sampson, MD, director of the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai, New York, and a member of the panel, said in an interview.
“It is critical that pediatricians and family practitioners identify infants at high risk for developing peanut allergy (severe atopic dermatitis or egg allergy) between 4 and 6 months of age, evaluate them, or refer them to a food allergy specialist when necessary,” Dr. Sampson said.
“Have parents introduce peanut into the infant’s diet on a regular basis. It is important for parents to notify their pediatrician or family physician if they suspect their infant is at high risk for developing peanut allergy,” he added. “Also, once early peanut introduction is started, it is important that parents continue to provide peanut on a regular basis for several years.”
Next steps for research include pursuing other allergens, said Dr. Sampson. “Similar studies need to be done to determine if early introduction of other foods, such as milk, egg, [or] tree nuts will prevent these common food allergies in high-risk infants.”
Also, it will be important to study whether infants at mild to moderate risk for developing peanut or other food allergies as evidenced by mild to moderate eczema will experience the same benefits in allergy risk reduction seen in the highest-risk children, he added.
The panelists had no relevant financial conflicts to disclose.
Introducing peanut foods to children who are at different levels of risk for peanut allergies may prevent or mitigate the risk, and the strategies for clinicians are explained in new addendum guidelines issued by an expert panel sponsored by the National Institute of Allergy and Infectious Diseases.
The guidelines were published online Jan. 5 in the Journal of Allergy and Clinical Immunology (J Allergy Clin Immunol. 2017. doi: 10.1016/j.jaci.2016.10.010).
“In the majority of patients, peanut allergy begins early in life and persists as a lifelong problem,” wrote lead author Alkis Togias, MD, of NIAID in Bethesda, Md., and colleagues. Previous guidelines published in 2010 did not provide specific treatment strategies for peanut allergies because of a lack of research, but the significant results of the Learning Early About Peanut Allergy (LEAP) study suggested that early exposure to peanut-containing foods reduces the risk of developing allergies.
The NIAID’s Guidelines Coordinating Committee conducted a literature review covering research from January 2010 to June 2016 and developed addendum guidelines, as follows:
For infants with severe eczema, egg allergies, or both, peanut-containing foods should be introduced at 4-6 months of age at the earliest, after the introduction of other solid foods to confirm developmental readiness. If the infant is developmentally ready for solids, clinicians should “strongly consider” evaluation by peanut-specific IgE (peanut sIgE) measurement and/or skin prick test before introducing peanut products to determine the potential sensitivity and need for supervised feeding vs. feeding at home.
If dietary peanut will be introduced based on the recommendations, “the total amount of peanut protein to be regularly consumed per week should be approximately 6 to 7 g over 3 or more feedings,” the authors wrote.
However, children already identified as allergic to peanut should practice strict peanut avoidance, they added. In addition, they recommend that clinicians review risks and benefits for high-risk children who may have family members with established peanut allergies.
For infants with mild to moderate eczema, the recommendation is to introduce peanut-containing foods at approximately 6 months of age, “in accordance with family preferences and cultural practices,” after the introduction of other solid foods, to help reduce the risk of peanut allergies. The expert panel recommends that infants in this moderate-risk category may receive peanut foods at home without an office visit, although caregivers or clinicians may choose an office visit for supervised feeding, evaluation, or both. Although the LEAP trial did not target infants with mild or moderate eczema, the panel has no reason to believe that the protective mechanisms are different in these children.
For infants with no eczema or any food allergies, the guidelines recommend introducing peanut-containing foods at any age, as appropriate and in keeping with a family’s preferences and cultural practices.
“The early introduction of dietary peanut in children without risk factors for peanut allergy is generally anticipated to be safe and to contribute modestly to an overall reduction in the prevalence of peanut allergy,” the researchers said.
The findings of the LEAP and accompanying LEAP-On trials were so compelling (approximately 80% relative reduction in peanut allergy at 5 years of age for peanut-exposed children, compared with standard of care) that the NIAID and expert panel “felt it was necessary to review and revise the previous recommendations from the 2010 guidelines on the diagnosis and management of food allergy,” Hugh Sampson, MD, director of the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai, New York, and a member of the panel, said in an interview.
“It is critical that pediatricians and family practitioners identify infants at high risk for developing peanut allergy (severe atopic dermatitis or egg allergy) between 4 and 6 months of age, evaluate them, or refer them to a food allergy specialist when necessary,” Dr. Sampson said.
“Have parents introduce peanut into the infant’s diet on a regular basis. It is important for parents to notify their pediatrician or family physician if they suspect their infant is at high risk for developing peanut allergy,” he added. “Also, once early peanut introduction is started, it is important that parents continue to provide peanut on a regular basis for several years.”
Next steps for research include pursuing other allergens, said Dr. Sampson. “Similar studies need to be done to determine if early introduction of other foods, such as milk, egg, [or] tree nuts will prevent these common food allergies in high-risk infants.”
Also, it will be important to study whether infants at mild to moderate risk for developing peanut or other food allergies as evidenced by mild to moderate eczema will experience the same benefits in allergy risk reduction seen in the highest-risk children, he added.
The panelists had no relevant financial conflicts to disclose.
Introducing peanut foods to children who are at different levels of risk for peanut allergies may prevent or mitigate the risk, and the strategies for clinicians are explained in new addendum guidelines issued by an expert panel sponsored by the National Institute of Allergy and Infectious Diseases.
The guidelines were published online Jan. 5 in the Journal of Allergy and Clinical Immunology (J Allergy Clin Immunol. 2017. doi: 10.1016/j.jaci.2016.10.010).
“In the majority of patients, peanut allergy begins early in life and persists as a lifelong problem,” wrote lead author Alkis Togias, MD, of NIAID in Bethesda, Md., and colleagues. Previous guidelines published in 2010 did not provide specific treatment strategies for peanut allergies because of a lack of research, but the significant results of the Learning Early About Peanut Allergy (LEAP) study suggested that early exposure to peanut-containing foods reduces the risk of developing allergies.
The NIAID’s Guidelines Coordinating Committee conducted a literature review covering research from January 2010 to June 2016 and developed addendum guidelines, as follows:
For infants with severe eczema, egg allergies, or both, peanut-containing foods should be introduced at 4-6 months of age at the earliest, after the introduction of other solid foods to confirm developmental readiness. If the infant is developmentally ready for solids, clinicians should “strongly consider” evaluation by peanut-specific IgE (peanut sIgE) measurement and/or skin prick test before introducing peanut products to determine the potential sensitivity and need for supervised feeding vs. feeding at home.
If dietary peanut will be introduced based on the recommendations, “the total amount of peanut protein to be regularly consumed per week should be approximately 6 to 7 g over 3 or more feedings,” the authors wrote.
However, children already identified as allergic to peanut should practice strict peanut avoidance, they added. In addition, they recommend that clinicians review risks and benefits for high-risk children who may have family members with established peanut allergies.
For infants with mild to moderate eczema, the recommendation is to introduce peanut-containing foods at approximately 6 months of age, “in accordance with family preferences and cultural practices,” after the introduction of other solid foods, to help reduce the risk of peanut allergies. The expert panel recommends that infants in this moderate-risk category may receive peanut foods at home without an office visit, although caregivers or clinicians may choose an office visit for supervised feeding, evaluation, or both. Although the LEAP trial did not target infants with mild or moderate eczema, the panel has no reason to believe that the protective mechanisms are different in these children.
For infants with no eczema or any food allergies, the guidelines recommend introducing peanut-containing foods at any age, as appropriate and in keeping with a family’s preferences and cultural practices.
“The early introduction of dietary peanut in children without risk factors for peanut allergy is generally anticipated to be safe and to contribute modestly to an overall reduction in the prevalence of peanut allergy,” the researchers said.
The findings of the LEAP and accompanying LEAP-On trials were so compelling (approximately 80% relative reduction in peanut allergy at 5 years of age for peanut-exposed children, compared with standard of care) that the NIAID and expert panel “felt it was necessary to review and revise the previous recommendations from the 2010 guidelines on the diagnosis and management of food allergy,” Hugh Sampson, MD, director of the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai, New York, and a member of the panel, said in an interview.
“It is critical that pediatricians and family practitioners identify infants at high risk for developing peanut allergy (severe atopic dermatitis or egg allergy) between 4 and 6 months of age, evaluate them, or refer them to a food allergy specialist when necessary,” Dr. Sampson said.
“Have parents introduce peanut into the infant’s diet on a regular basis. It is important for parents to notify their pediatrician or family physician if they suspect their infant is at high risk for developing peanut allergy,” he added. “Also, once early peanut introduction is started, it is important that parents continue to provide peanut on a regular basis for several years.”
Next steps for research include pursuing other allergens, said Dr. Sampson. “Similar studies need to be done to determine if early introduction of other foods, such as milk, egg, [or] tree nuts will prevent these common food allergies in high-risk infants.”
Also, it will be important to study whether infants at mild to moderate risk for developing peanut or other food allergies as evidenced by mild to moderate eczema will experience the same benefits in allergy risk reduction seen in the highest-risk children, he added.
The panelists had no relevant financial conflicts to disclose.
FROM THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY
Children in Taiwan being undervaccinated for pertussis
Up to one-fifth of pertussis cases in Taiwanese children aged 3-35 months from 1996 to 2012 could have been prevented with on-time vaccination, reported Wan-Ting Huang and coauthors at the Taiwan Centers for Disease Control, Taipei.
Although vaccination coverage was 97.4% for three or more pertussis vaccine doses among Taiwanese children aged 12-23 months, many had not received proper vaccination at the right time.
“The study indicated that in Taiwan, undervaccination was decreasing but had placed young children at risk for pertussis,” the authors wrote.
Read the full study from Human Vaccines & Immunotherapeutics (2016. doi: 10.1080/21645515.2016.1249552).
Up to one-fifth of pertussis cases in Taiwanese children aged 3-35 months from 1996 to 2012 could have been prevented with on-time vaccination, reported Wan-Ting Huang and coauthors at the Taiwan Centers for Disease Control, Taipei.
Although vaccination coverage was 97.4% for three or more pertussis vaccine doses among Taiwanese children aged 12-23 months, many had not received proper vaccination at the right time.
“The study indicated that in Taiwan, undervaccination was decreasing but had placed young children at risk for pertussis,” the authors wrote.
Read the full study from Human Vaccines & Immunotherapeutics (2016. doi: 10.1080/21645515.2016.1249552).
Up to one-fifth of pertussis cases in Taiwanese children aged 3-35 months from 1996 to 2012 could have been prevented with on-time vaccination, reported Wan-Ting Huang and coauthors at the Taiwan Centers for Disease Control, Taipei.
Although vaccination coverage was 97.4% for three or more pertussis vaccine doses among Taiwanese children aged 12-23 months, many had not received proper vaccination at the right time.
“The study indicated that in Taiwan, undervaccination was decreasing but had placed young children at risk for pertussis,” the authors wrote.
Read the full study from Human Vaccines & Immunotherapeutics (2016. doi: 10.1080/21645515.2016.1249552).
FROM HUMAN VACCINES & IMMUNOTHERAPEUTICS
Reye’s syndrome: Time to remind the parents
It is that time of year again. We are in the midst of flu season, which means that it is time to remind our patients’ parents about the importance of using acetaminophen instead of aspirin. This fact became evident when several guardians of our patients came in within a few days of each other in late November to early December unaware of the dangers of giving their children aspirin and other salicylate medications.
Case 1: A 4-year-old boy presented with mild diarrhea, but otherwise was clinically well. The diarrhea started while visiting family in Mexico. The mother took out a small bottle of Pepto-Bismol (bismuth subsalicylate) liquid, which she gave him 2 days previously. The bottle did have, in small font, a warning about Reye’s syndrome on the label, which the mother did not notice. She also did not think it pertained to her son anyway. During the visit, she was counseled on this being early influenza season and the avoidance of salicylate products since the 1980s in children, with the exception of cardiac uses.
Case 2: A 16-year-old male presented with his grandmother with a few scattered vesicles and low-grade fever. He had plans to go to Florida in a few days with friends and wished to know if he would be able to go. He had one dose of varicella vaccine when he was a toddler. Varicella IgM and IgG were ordered. When asked, the grandmother stated that she did not remember the warning signs about Reye’s syndrome posted in the pharmacies 30 years ago. In addition, she vaguely remembered baby aspirin not being made anymore, but she could not remember the reason why.
Case 3: An 18-year-old female with a medical history of occasional migraines controlled with over-the-counter products presented for a school form. Her mother mentioned that a relative had influenza symptoms. When we looked up the migraine medication, it was a generic aspirin/caffeine product. When counseled on Reye’s syndrome, the mother did not remember it at all, even though she was a teenager in the 1980s; she stated that she did remember her mom using only Tylenol for her illnesses.
Reye’s syndrome, a rare but serious condition causing liver degeneration and encephalopathy presenting in children younger than 18 years, was first described in 1963.1 Symptoms include mental confusion, vomiting, and even coma. The cause is unknown; however, salicylates have been implicated as a possible causative agent.
Products containing salicylate include but are not limited to aspirin and Pepto-Bismol. Studies linked Reye’s syndrome epidemiologically to recent illness with influenza or varicella and the use of aspirin. In 1978, the Centers for Disease Control and Prevention was informed that several children developed Reye’s syndrome during an influenza outbreak, and by 1980, the CDC demonstrated a link between those patients and the administration of salicylate-containing medications.2 Around the same time, more studies came out to support these findings. In 1980, 555 cases of Reye’s syndrome were reported in the United States. To decrease the occurrence, the CDC, American Academy of Pediatrics, and the U.S. Surgeon General tried to raise awareness of the association between Reye’s syndrome and aspirin by publishing journals, releasing warning statements, and including a “Black Box” warning in 1986 informing parents to not give aspirin to children and teenagers with influenza or chicken pox. Baby aspirin was removed from use for routine fevers in the mid-1980s and large warning signs would be found in every pharmacy for about 10 years. These warning signs are gone now.
As pediatricians and other primary care physicians, we have so many topics that we must address in the limited time we have allotted for each patient. However, we need to remind our patients and their parents about Reye’s syndrome and the importance of avoiding aspirin and salicylate products in children. Due to the public awareness of Reye’s syndrome in the 1980s and into the 1990s, the incidence decreased.2 From 1987 to 1993, fewer than 37 cases were reported in the United States and from 1994 to 1997, fewer than 2 cases were reported.
This demonstrates the importance of educating our patients and their parents about this syndrome and ways to avoid it. Based on the three clinical cases presented, it is clear that at least some of our patient’s guardians are unaware of this threat to their children. As physicians, it is our responsibility to educate our patient populations, but we should also ask our friends at our local supermarkets and pharmacies to dust off those old warning signs and help spread the word. While we are in flu season, let’s not forget to take a few minutes to inform our patients about this awful, but preventable syndrome.
References
1. Pediatrics. 1980 Dec;66(6):859-64.
2. J Gen Intern Med. 2012 Dec;27(12):1697-703.
Rachel Masia is a third-year medical student at Rowan University School of Osteopathic Medicine, Stratford, N.J. Dr. Alan Masia, Ms. Masia’s father, has a practice in Toms River, N.J. They said they had no relevant financial disclosures.
It is that time of year again. We are in the midst of flu season, which means that it is time to remind our patients’ parents about the importance of using acetaminophen instead of aspirin. This fact became evident when several guardians of our patients came in within a few days of each other in late November to early December unaware of the dangers of giving their children aspirin and other salicylate medications.
Case 1: A 4-year-old boy presented with mild diarrhea, but otherwise was clinically well. The diarrhea started while visiting family in Mexico. The mother took out a small bottle of Pepto-Bismol (bismuth subsalicylate) liquid, which she gave him 2 days previously. The bottle did have, in small font, a warning about Reye’s syndrome on the label, which the mother did not notice. She also did not think it pertained to her son anyway. During the visit, she was counseled on this being early influenza season and the avoidance of salicylate products since the 1980s in children, with the exception of cardiac uses.
Case 2: A 16-year-old male presented with his grandmother with a few scattered vesicles and low-grade fever. He had plans to go to Florida in a few days with friends and wished to know if he would be able to go. He had one dose of varicella vaccine when he was a toddler. Varicella IgM and IgG were ordered. When asked, the grandmother stated that she did not remember the warning signs about Reye’s syndrome posted in the pharmacies 30 years ago. In addition, she vaguely remembered baby aspirin not being made anymore, but she could not remember the reason why.
Case 3: An 18-year-old female with a medical history of occasional migraines controlled with over-the-counter products presented for a school form. Her mother mentioned that a relative had influenza symptoms. When we looked up the migraine medication, it was a generic aspirin/caffeine product. When counseled on Reye’s syndrome, the mother did not remember it at all, even though she was a teenager in the 1980s; she stated that she did remember her mom using only Tylenol for her illnesses.
Reye’s syndrome, a rare but serious condition causing liver degeneration and encephalopathy presenting in children younger than 18 years, was first described in 1963.1 Symptoms include mental confusion, vomiting, and even coma. The cause is unknown; however, salicylates have been implicated as a possible causative agent.
Products containing salicylate include but are not limited to aspirin and Pepto-Bismol. Studies linked Reye’s syndrome epidemiologically to recent illness with influenza or varicella and the use of aspirin. In 1978, the Centers for Disease Control and Prevention was informed that several children developed Reye’s syndrome during an influenza outbreak, and by 1980, the CDC demonstrated a link between those patients and the administration of salicylate-containing medications.2 Around the same time, more studies came out to support these findings. In 1980, 555 cases of Reye’s syndrome were reported in the United States. To decrease the occurrence, the CDC, American Academy of Pediatrics, and the U.S. Surgeon General tried to raise awareness of the association between Reye’s syndrome and aspirin by publishing journals, releasing warning statements, and including a “Black Box” warning in 1986 informing parents to not give aspirin to children and teenagers with influenza or chicken pox. Baby aspirin was removed from use for routine fevers in the mid-1980s and large warning signs would be found in every pharmacy for about 10 years. These warning signs are gone now.
As pediatricians and other primary care physicians, we have so many topics that we must address in the limited time we have allotted for each patient. However, we need to remind our patients and their parents about Reye’s syndrome and the importance of avoiding aspirin and salicylate products in children. Due to the public awareness of Reye’s syndrome in the 1980s and into the 1990s, the incidence decreased.2 From 1987 to 1993, fewer than 37 cases were reported in the United States and from 1994 to 1997, fewer than 2 cases were reported.
This demonstrates the importance of educating our patients and their parents about this syndrome and ways to avoid it. Based on the three clinical cases presented, it is clear that at least some of our patient’s guardians are unaware of this threat to their children. As physicians, it is our responsibility to educate our patient populations, but we should also ask our friends at our local supermarkets and pharmacies to dust off those old warning signs and help spread the word. While we are in flu season, let’s not forget to take a few minutes to inform our patients about this awful, but preventable syndrome.
References
1. Pediatrics. 1980 Dec;66(6):859-64.
2. J Gen Intern Med. 2012 Dec;27(12):1697-703.
Rachel Masia is a third-year medical student at Rowan University School of Osteopathic Medicine, Stratford, N.J. Dr. Alan Masia, Ms. Masia’s father, has a practice in Toms River, N.J. They said they had no relevant financial disclosures.
It is that time of year again. We are in the midst of flu season, which means that it is time to remind our patients’ parents about the importance of using acetaminophen instead of aspirin. This fact became evident when several guardians of our patients came in within a few days of each other in late November to early December unaware of the dangers of giving their children aspirin and other salicylate medications.
Case 1: A 4-year-old boy presented with mild diarrhea, but otherwise was clinically well. The diarrhea started while visiting family in Mexico. The mother took out a small bottle of Pepto-Bismol (bismuth subsalicylate) liquid, which she gave him 2 days previously. The bottle did have, in small font, a warning about Reye’s syndrome on the label, which the mother did not notice. She also did not think it pertained to her son anyway. During the visit, she was counseled on this being early influenza season and the avoidance of salicylate products since the 1980s in children, with the exception of cardiac uses.
Case 2: A 16-year-old male presented with his grandmother with a few scattered vesicles and low-grade fever. He had plans to go to Florida in a few days with friends and wished to know if he would be able to go. He had one dose of varicella vaccine when he was a toddler. Varicella IgM and IgG were ordered. When asked, the grandmother stated that she did not remember the warning signs about Reye’s syndrome posted in the pharmacies 30 years ago. In addition, she vaguely remembered baby aspirin not being made anymore, but she could not remember the reason why.
Case 3: An 18-year-old female with a medical history of occasional migraines controlled with over-the-counter products presented for a school form. Her mother mentioned that a relative had influenza symptoms. When we looked up the migraine medication, it was a generic aspirin/caffeine product. When counseled on Reye’s syndrome, the mother did not remember it at all, even though she was a teenager in the 1980s; she stated that she did remember her mom using only Tylenol for her illnesses.
Reye’s syndrome, a rare but serious condition causing liver degeneration and encephalopathy presenting in children younger than 18 years, was first described in 1963.1 Symptoms include mental confusion, vomiting, and even coma. The cause is unknown; however, salicylates have been implicated as a possible causative agent.
Products containing salicylate include but are not limited to aspirin and Pepto-Bismol. Studies linked Reye’s syndrome epidemiologically to recent illness with influenza or varicella and the use of aspirin. In 1978, the Centers for Disease Control and Prevention was informed that several children developed Reye’s syndrome during an influenza outbreak, and by 1980, the CDC demonstrated a link between those patients and the administration of salicylate-containing medications.2 Around the same time, more studies came out to support these findings. In 1980, 555 cases of Reye’s syndrome were reported in the United States. To decrease the occurrence, the CDC, American Academy of Pediatrics, and the U.S. Surgeon General tried to raise awareness of the association between Reye’s syndrome and aspirin by publishing journals, releasing warning statements, and including a “Black Box” warning in 1986 informing parents to not give aspirin to children and teenagers with influenza or chicken pox. Baby aspirin was removed from use for routine fevers in the mid-1980s and large warning signs would be found in every pharmacy for about 10 years. These warning signs are gone now.
As pediatricians and other primary care physicians, we have so many topics that we must address in the limited time we have allotted for each patient. However, we need to remind our patients and their parents about Reye’s syndrome and the importance of avoiding aspirin and salicylate products in children. Due to the public awareness of Reye’s syndrome in the 1980s and into the 1990s, the incidence decreased.2 From 1987 to 1993, fewer than 37 cases were reported in the United States and from 1994 to 1997, fewer than 2 cases were reported.
This demonstrates the importance of educating our patients and their parents about this syndrome and ways to avoid it. Based on the three clinical cases presented, it is clear that at least some of our patient’s guardians are unaware of this threat to their children. As physicians, it is our responsibility to educate our patient populations, but we should also ask our friends at our local supermarkets and pharmacies to dust off those old warning signs and help spread the word. While we are in flu season, let’s not forget to take a few minutes to inform our patients about this awful, but preventable syndrome.
References
1. Pediatrics. 1980 Dec;66(6):859-64.
2. J Gen Intern Med. 2012 Dec;27(12):1697-703.
Rachel Masia is a third-year medical student at Rowan University School of Osteopathic Medicine, Stratford, N.J. Dr. Alan Masia, Ms. Masia’s father, has a practice in Toms River, N.J. They said they had no relevant financial disclosures.